wisconsin partnership program · what were the project’s objectives and to what ... this team...

DHFS-OSF-CDSD • 1 S. Pinckney St., Suite 340 • PO Box 1379 • Madison, WI • 53701-1379 • Tel: 608/261-8877 • Fax: 608/266-5629http://www.dhfs.state.wi.us/About/osf/osf-WPP.html

Made possible by a grant from the Robert Wood Johnson Foundation

Wisconsin Partnership ProgramDepartment of Health and Family Services

Office of Strategic FinanceCenter for Delivery Systems Development

FINAL GRANT REPORT

Building a Statewide System of Consumer-Responsive, Integrated Carefor People with Chronic Illness or Disability

Robert Wood Johnson Grant # 23246October 1, 1994 – December 31, 1999(no-cost extension 10/1/97 – 12/31/99)

Current Date: March 9, 2000

1. What were the project’s objectives and to what extent has the project met theseobjectives?

In our October 1994 grant application, we proposed to develop, implement and research twoinnovative managed care models that would integrate acute and long term care throughcommunity-based organizations. One model would serve frail elderly people and the otherwould serve adults with physical disabilities. We planned to call this innovative model the“Wisconsin Partnership Program.” We proposed that a key feature of the PartnershipProgram would be a multidisciplinary team that consisted of the member, a social worker, aregistered nurse, and a nurse practitioner. This team would be responsible for coordinatingthe member’s care. The Partnership Program would emphasize the role of the nursepractitioner in bridging the gap between medical and social services so that fragmentedservices would be integrated.

By the end of the grant period, we projected that the elderly model would be fullyoperational; the physical disabilities model would be pilot-tested; the quality assurancesystem would be designed and implemented; and research results would be available toassess operational progress, consumer experiences, quality of care, and impact of key designfeatures. Finally, we stated that a program development process would be designed andtested with secondary sites for the two models to ensure that the Robert Wood JohnsonFoundation grant became a self-sustaining system of replication and model improvement.

That was five years ago. Today, looking back at our original grant proposal it is obvious thatwe have accomplished our original objectives. During the past five years we have:• Implemented the Partnership Program at four community-based organizations serving

residents in five counties in Wisconsin;• Secured an 1115/222 Medicaid/Medicare waiver from the federal Health Care Financing

Administration in October 1998 which allows the Partnership organizations to receivecapitation payments from both Medicare and Medicaid;

• Served nearly 1,000 people in the Partnership Program over the course of the grant; netenrollment on December 31, 1999 was 726 members (see the following page for a chartof census growth over the last three years);

Wisconsin Partnership Program

WI Partnership Program Census Growth (1/1/97-12/31/99)

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• Developed the infrastructure and capacity necessary to operate a model that integrateshealth and long term care services for people with chronic conditions and illnesses.

• Reduced service fragmentation through specific implementation strategies, includingunified financing, continuity across the spectrum of provider types and service settings,the interdisciplinary care team, and comprehensive service plans emphasizing consumerchoice, communication, prevention, continuity and quality.

The Wisconsin Partnership Program is a huge success and demonstrates that integrating acuteand long term care is feasible, can be implemented by community-based organizations, andworks for multiple age and target groups in various geographic settings, urban and rural.Members also represent the full range of American cultural diversity, including émigrés fromRussia, Cambodia, China, Mexico, South America, and the Indian subcontinent.A summary of detailed accomplishments, organized by Partnership site, is included in thenext section.

The objectives of the Wisconsin Partnership Program can be organized into the followingthree areas:

1. WPP Sites - Establish and implement the organizational and program structure forthe Partnership Program for elderly people and people with physical disabilities;

2. DHFS - Establish the program infrastructure within the Department of Health andFamily Services to support and monitor the Partnership Program; and

3. Quality - Conduct interviews and observations of management, clinical teammembers, participants and participants’ families to identify service quality standards.Demonstrate those quality standards in program implementation and oversight.


Objective 1 – The Objectives of the WPP sites during the grant were to:• Provide comprehensive care to people who meet nursing home admission criteria;• Improve functional and clinical outcomes of consumers;• Retain the continuity of care and preventive health elements successfully incorporated

in current PACE sites;• Allow consumers to retain choice of primary care physicians and to participate in the

program without attending adult day care;• Maximize the ability of consumers to live in their own homes, to participate in

community life, and to be engaged in the decision-making processes regarding theirown care;

• Minimize reliance on institutional care (hospitals, nursing homes, and group livingenvironments over 4 beds); and

• Reduce acute/long term care costs primarily by lowering the need for acute careintervention (e.g., hospitalization), compared to the fee-for-service system.

Objective 1 –Accomplishments:

Community Living Alliance1 (CLA)CLA is small community-based non-profit organization in Madison that serves adults withsignificant physical disabilities that reside in Dane County. CLA’s background is as anIndependent Living Center, and as such, fosters the independence of members by developingand operating in a way that seeks their participation in the governance of the organization,staffing, program design, quality improvement, program evaluation and resource allocation.CLA was selected as a Partnership site in October 1994 as a result of a Request for Proposalsissued by the Department of Health and Family Services.

Census – CLA began enrolling members in May 1996. At the end of the grant there were 140members enrolled; a net growth of approximately 2.5 members per month. Enrollment atCLA has not been as rapid as might have been hoped.

CLA’s slow census growth can partly be attributed to the prominence of members withsignificant mental health issues and/or multiple diagnoses and degenerative disabilities.Approximately 42% of CLA’s members have a diagnosed mental health and/or substanceabuse problem. Further, only 46% of members have what many might regard as “typical”physical disabilities, i.e., spinal cord injuries, MS, cerebral palsy, etc. The added complexitypresented by the comorbidity of mental health and alcohol and drug issues along withsignificant physical conditions has prompted CLA to approach new referrals slowly, makingsure that all necessary services are in place prior to enrollment.

The majority of CLA members have chronic health conditions such as diabetes and heart andlung diseases. Many of these members have multiple diagnoses and complex conditions andin many cases are unwilling to follow a plan of care without significant involvement of thecare management team. This has meant that the team size to member ratio has remainedsmall, with 25 members per team.

1 Formerly Access to Independence. In 1998, Access to Independence separated into two corporations – Accessto Independence and Community Living Alliance (CLA). The Wisconsin Partnership Program for people withphysical disabilities began operating under CLA on January 1, 1998.


• When CLA first started serving people in the Partnership Program, CLA anticipated themajority of their members would have personal care and other long term care needs.However, the participants that are actually enrolled have significantly more complex medicaland social issues than was anticipated. This complex population required CLA to develop theinfrastructure needed to operate a program with more expertise in acute and primary healthcare than originally expected. In order to function effectively in the medical arena, policies,procedures and adequate oversight of activities are necessary to assure good quality of care.This is a challenge for small community-based social service organizations.

• Staff Recruitment and Selection – Each interdisciplinary team at CLA consists of .5 FTEnurse practitioner, one registered nurse, and one social service coordinator. In addition to theteam, “float” nurses and team coordinators facilitate assessments and follow-up on healthconcerns. At the end of the grant, CLA had seven interdisciplinary teams in place to servetheir members plus a total of 146 personal living assistants.

• Provider Network – Currently, CLA works with 19 clinics, 3 hospitals and 2 health systemsin Dane County. CLA’s provider network also includes of durable medical equipment(DME) providers, chiropractors, pharmacies, AODA providers, and nursing homes.

• Physician Recruitment – The CLA Partnership Program currently has 34 physicians on itspanel for members to choose from. Physician recruitment has been slow but steadythroughout the project. CLA has experienced difficulty finding physicians to agree to takemore than a few (up to 5) of their members. Medicaid recipients are often viewed in thephysician community as being very difficult to work with, unmotivated to follow the plan ofcare and often missing appointments. CLA has attempted to overcome this barrier bystressing the support the Partnership team (especially the nurse practitioner) provides to thephysician. One role of the nurse practitioner is to form a collaborative practice arrangementwith the physician, which relieves the physician of some of the more routine care provided tomembers and, also, augments the primary care that the physician provides.

• Outcomes – During the past three years, CLA has seen improved clinical and functionaloutcomes for their members. In the broadest sense, CLA members prefer to live in their ownhomes. At the end of 1999, 94% of CLA members were living outside of an institutional orsubstitute care setting. Historically, 98% of members have lived in their own home or that ofa relative.

Other utilization data shows an increase in nursing home days between 1998 and 1999 whichreflects the medical complexity of members, and to some extent, the lack of availability ofpersonal care workers. Emergency room visits were also higher in 1999. According to arecent study conducted internally at CLA, most emergency room visits were during the dayand most were authorized by staff. Hospital admissions are also growing. Nurse Practitionersevaluate every admission to determine whether or not it could have been prevented, and in99% of cases found the admission was not preventable. This reflects the acuity of themembers that CLA is serving. CLA members require a high number of medications withmedications for depression being the highest category, followed by analgesics/narcotics.


Elder Care of Dane County (Elder Care)In December 1995, Elder Care of Dane County became the first agency to begin enrollingmembers into the Partnership Program. Elder Care has been a community-based provider of longterm care services in Madison since 1976. Elder Care entered the arena of integrated servicedelivery via the PACE program in January 1995. This experience provided Elder Care theopportunity to develop the organizational capacity necessary to administer a complex,comprehensive, capitated program such as the Partnership Program. Elder Care served as anexcellent resource for the other Partnership organizations as they brought up their individualprograms.

• Census – Elder Care began enrolling members in December 1995, and they have served 335members over the five-year grant period. On December 31, 1999 there were 241 membersenrolled. On average, Elder Care enrolls 8 members per month. Elder Care’s largest referralsource has been the Dane County waitlist for long term care services and other countyreferral sources.

• Staff Recruitment and Selection – Each interdisciplinary team at Elder Care consists of nursepractitioner, two registered nurses, and one social service coordinator. At the end of thereporting period, Elder Care had six interdisciplinary teams.

• Provider Network – Elder Care’s provider network for acute and primary care is comprisedof four area hospitals and five participating physician group practices with 32 clinics.

• Physician Recruitment – Elder Care’s physician panel is comprised of 71 physicians. Ofthese, 73% are trained in internal medicine and 27% are trained in Family Practice; 7% of allphysicians have advanced certification in geriatrics.

Overall, Elder Care has found that a limited or restricted panel of physicians has been moresuccessful than contracting with every physician that members bring to the program. At firstElder Care sought to enroll all willing physicians in their panel, however, this arrangementproved unmanageable and hindered the development of collaborative working relationshipsbetween physicians and nurse practitioners, which are essential to the success of Partnership.A limited network of physicians is more manageable in terms of assuring quality, ensuringthat providers understand the Partnership model, and administering Medicaid and Medicarerequirements for subcontracted services.

• Outcomes – The majority of Elder Care’s members live the community with 86% living in aprivate home, 2% living in a nursing facility and 13% living in a CBRF or Adult FamilyHome.

In order to determine whether emergency room visits and hospital admissions werenecessary, Elder Care staff developed and implemented a process for retrospective review ofadmissions and emergency room visits, using a standard data collection form. Staff evaluatethe appropriateness of care preceding and concurrent with these events, and maintain recordsof their findings. Most events were found to be not preventable. Records are tracked by thequality committee to monitor for trends and identify opportunities for specific qualityimprovement activities


Community Care for the Elderly (CCE)In 1990, Community Care for the Elderly, located in Milwaukee, was the first agency inWisconsin to provide an integrated model of community-based, managed long term care forolder adults through its PACE program. CCE was the second site selected to demonstrate thePartnership model for the frail elderly and began serving members in 1996. CCE isdemonstrating a variation of the Partnership Program model where interdisciplinary teams arephysically located in centralized locations where member enrollment is the heaviest. Two ofCCE’s interdisciplinary teams are physically located at elderly-only housing units and one teamis co-located in a hospital where CCE has developed a dementia adult daycare program.Partnership services are also taken out to members not living in these congregate housingsituations but who are in the immediate geographical area. CCE finds that this type ofarrangement works well in a large urban area, and CCE considers their development ofinterdisciplinary teams located closer to the member’s residence or neighborhood to be one ofthe major accomplishments of their program.

• Census – CCE began enrolling members in 1996; on December 31, 1999, 162 members wereenrolled. CCE has served a total of 233 people over the course of the last three years. Thereis a greater net growth enrollment in CCE’s Partnership Program than in its PACE program.

• Staff Recruitment and Selection – CCE works with four interdisciplinary teams and asmentioned above, each team serves a specific geographic area. The size and make-up of eachteam varies depending on the area served.

• Provider Network – CCE works with seven area clinics and all three major hospital networksin the Milwaukee area.

• Physician Recruitment – On December 31, 1999 there were a total of 28 primary carephysicians involved in the Partnership Program. CCE has over 200 specialists available toserve participants.

Prior to its involvement in Partnership, CCE operated a PACE site which uses a staffphysician. The use of community physicians to provide primary care is a significantdeparture from the PACE model. After approximately three years of experience with thePartnership model, CCE reports that the use of community-based physicians as providers ofprimary care appears to function adequately. CCE believes the model necessitates theutilization of an experienced nurse practitioner to accomplish the frequent monitoring andintervention of multiple chronic diseases in the population.

• Outcomes – CCE reports that the service delivery model utilizing increased in-home servicesand a reduced interdisciplinary model of care has been effective in providing care tomembers. However, the CCE Partnership Program continues to rely upon the infrastructuredeveloped for PACE, and it is difficult to evaluate the effect of the organization separately.

Partnership members at CCE have enjoyed a greater than 90% community living situationover the history of the program. As of December 31, 1999, 151 members lived in thecommunity, two members lived in a nursing home, and nine members lived in a CBRF.


Within the past year, CCE has noted trends in higher utilization of pharmacy and inpatienthospitalizations for Partnership members. CCE plans to monitor these trends closely in thefuture.

Community Health Partnership2 (CHP)CHP was the first “replication” site for the Partnership demonstration. The Department of Healthand Family Services selected CHP in 1995 through a competitive request for proposals (RFP)process. CHP is the only Partnership agency to serve both target groups (frail elderly 65 andover and adults with disabilities ages 18-64) in a three county area (Eau Claire, Dunn andChippewa Counties). When CHP began their Partnership Program, the other three Partnershipsites were already operational and a lot of the foundation had already been laid by the other sites.CHP benefited from the other sites, who pitched in to offer technical assistance and invaluableadvice.

• Census – After 19 months of planning, CHP started to enroll members on May 1, 1997. Atthe end of the grant period, enrollment was 183 (133 elderly, 50 physically disabled); anaverage of 5.9 enrollments per month.

• Staff Recruitment and Selection – CHP works with five interdisciplinary teams. Each team iscomprised of a nurse practitioner, registered nurse, social services coordinator, and teamassistant. In addition, CHP has with 120 daily living assistants available to serve members.

• Provider Network – Since CHP is located in a rural area and covers a geographic territory ofthree counties, developing a provider network has been challenging. Partnership sites arerequired to have all services available to Partnership members within a reasonable traveldistance. This requirement has forced CHP’s network to be extensive in size; some providersare even located in neighboring counties, as these providers are the most accessible to someof their members. CHP has 148 health and long term care providers in their network.However, the choice of providers is actually much larger due to several contracts coveringmore than one agency.

CHP has found that dentists are the most resistant to contracting with them. CHP reimbursesdentists the same as what the State Medicaid program is paying them, and this, in manyinstances, is well below their cost of providing dental services. Nevertheless, CHP iscurrently contracting with 15 dentists in the three county area—enough to meet the needs oftheir members. CHP also notes that many home health agencies view CHP as “competition”and have actively verbalized their concerns. Many agencies believed CHP would take theirclients away from them and not use the services of a home health agency because the becausethe care management team incorporates both RNs and NPs who are able to provide directcare. Over the course of the grant, CHP has been able to develop a more collaborativerelationship with home health agencies and the relationship between CHP and home healthagencies is dramatically better.

2 On January 1, 1999, the Partnership Program separated from the Center for Independent Living in WesternWisconsin to form a new private non-profit organization called Community Health Partnership, Inc.


• Physician Recruitment – CHP works with 75 primary care physicians in three major groups.Of these physicians, 68% are in family practice and 32% are in internal medicine. At leastthree of the family practice doctors are certified in Geriatrics.

• Outcomes – The majority of CHP members live in the community with 89% living in aprivate home, 8% living in a nursing facility, and 3% residing in a CBRF or group home.Other utilization outcomes show that, on average, the member to medication ratio is 9.25medications per member.

In 1998, CHP conducted a study of all members to compare hospital and nursing home days6 months prior to enrollment and 6 months after enrollment. CHP found that hospitalizationsand nursing home days substantially decreased after enrolling in the Partnership Program.Hospitalizations decreased from 88 to 49 and nursing home placements decreased from 31to 8.

Objective 2 – The objectives of the Department of Health and Family Services during thegrant were to:

• Develop and implement a self-sustaining system of program and organizationaldevelopment, model improvement and replication;

• Create a design whose essential elements can be applied to multiple age and target groupsin various geographic settings, urban and rural; and

• Secure a dual 1115/222 waiver that integrates Medicaid and Medicare.

Objective 2 – Accomplishments:The Wisconsin Partnership Program was developed through the assistance of the Robert WoodJohnson Foundation and has become a self-sustaining system. State staff originally funded byRWJ are now fully funded by Wisconsin. The individual Partnership organizations are operatingindependently of State sponsorship and are fully operational under the 1115/222 waiver.

Full implementation under the dual waiver has been the major accomplishment over the lastyear. HCFA conducted a site visit in November of 1998 so that the organizations could becomeoperational as soon as January 1, 1999. Since that time, negotiations have continued on suchitems as the Medicare+Choice contracts between HCFA and the sites, the reporting of budgetneutrality data to HCFA, and the creation of a grievance and appeal process that incorporatesboth Medicare and Medicaid principles and is transparent to consumers. DHFS and HCFA haveworked collaboratively on quality oversight, and DHFS is facilitating HCFA’s contractedevaluation, producing enrollment and utilization data and coordinating evaluation activities withthe Partnership contractors.

Objective 3 – The objectives for researching and assuring and improving quality duringthe grant were to:

• Carefully research and document implementation experiences and consumer responses;and

• Develop and test quality assurance protocols and quality indicators based on theexpressed values of consumers.


Objective 3 – Accomplishments:Over the past five years, the quality research team, led by Dr. Barbara Bowers at the Universityof Wisconsin-Madison School of Nursing has conducted formative and summative research inorder to understand how to think about quality from a variety of perspectives (provider,consumer, managerial), and how to design systems that promote quality in integrated,interdisciplinary, consumer centered care models.

To achieve these objectives, the quality research team took part in creating, and then studying,the interdisciplinary care management model centered on a team of providers that works incollaboration with the members being served in the program. Because such a model of care hadnever been implemented, the focus of the research team was on whether this integrated modelcould not only improve the quality of long term care, but lead to more consumer centered care.

Over the course of this demonstration project, the research team learned that an integrated caremanagement model, despite all of the implementation challenges it creates, does indeed result inmore consumer centered, long term care. In fact, from the consumer’s point of view, high qualitycare necessarily assumes consumer-centered care. The research also suggests that differences inhow people define quality – between consumers and providers, among providers, and betweenthe program and oversight agencies – influences the ability of Partnership organizations toprovide the highest quality care.

Several research-based products were developed to assist with the replication andimplementation of integrated care programs like Partnership. Much of the research team’s workfocused on the development of the interdisciplinary care team, and the shift in roles of teammembers that result from working collaboratively. Quality improvement/focused studyguidelines were also developed as ongoing quality systems at each Partnership site. Anevaluation designed to provide an opportunity for Partnership members to provide feedbackabout quality of care/service delivery was also developed. Each of the quality research productsreflect the perspectives of consumers, family members and health and long term care providers.A list of the research products developed during the grant is included in the attachedbibliography.

DHFS has incorporated the research findings in the Partnership Operations and OversightProtocols. Quality oversight in Partnership adapts components of the Quality ImprovementSystem for Managed Care (QISMC) to the specific quality standards of long term care recipientsas identified in the research.

2. What internal shortfalls, limitations, or challenges did the project encounter that wererelated to its funding level, design, collaborations, staffing, operations, or other projectfactors? Did any challenges internal to the National Program affect the project?

From the start, the Partnership organizations and the State recognized the need to purchase ordevelop an IT system for Partnership. A system was needed that would not only facilitate casemanagement and serve as a medical record, but would also capture encounter data and be ablecreate utilization reports. Given the complexity of the Partnership model, the IT systemrequirements were also complex and such a system was not readily available for purchase. In1996, the Partnership organizations began collaborating on the development of an IT system inorder to meet the specific needs of Partnership.


This IT system has evolved over time and is currently being tested at three of the Partnershiporganizations. The delay in the release of the final IT system has impaired the efforts of thePartnership organizations to maintain many records in an electronic format. This has affectedgood utilization review methods and the ability of the sites to deliver timely and accurateencounter data. The release of the final IT system is now scheduled for November 2000.

Another challenge that has faced the Partnership organizations is obtaining appropriate levels ofcare (LOC) determinations for Partnership members. Inconsistencies caused by both inter-raterreliability and the difference related to institutional versus community care have both fiscal andpublic relations impact on Partnership. Currently, a tool is being developed and tested for FamilyCare, the State’s long term care redesign program, that will hopefully deliver more consistentlevel of care determinations across settings and raters. When this new tool is validated inWisconsin, Partnership will seek an amendment to its 1115/222 waiver to allow the new tool tosubstitute for the current method of establishing level of care.

Partnership was designed to serve either people who are frail (age 55 and older) or adults withphysical disabilities. The frequency of comorbidity of these conditions with mental health andalcohol and other drug abuse (AODA) issues was unexpected. The frequency, as high as 65% atsome sites, has challenged the abilities of the Partnership organizations to respond to the needs ofthe whole person. Organizations have started to respond by acquiring the expertise necessary tointegrate this challenging area of service into their benefit package. In addition, the State isleading an effort to develop protocols to provide guidance to the organizations in addressing thecompliance issues associated with serving people who have mental illness and AODA issues.

Partnership seeks to build, to the greatest extent possible, a physician panel from primary carephysicians brought to the program by consumers wishing to enroll and/or by the Partnership sitesefforts to recruit primary and specialty physicians. However, one of the lessons learned inPartnership is that there can not be unrestricted growth of the physician panel. Quality of care,utilization management and integrity of the model are dependent on the establishment of a strongcollaborative working relationship between the primary care physicians and the nursepractitioners (NP). The relationships become increasingly difficult when the NP’s time andabilities are stretched between too many physicians. Site’s have worked hard to strike the properbalance between the size of enrollment and the physician panel. They have tested severalstrategies including securing physicians’ commitments to serve a minimum number ofPartnership members, recruiting whole clinics at one time-gaining efficiencies in timemanagement and physician orientation, and removing physicians from the panel who do notdemonstrate “buy-in” to the Partnership model. Experimentation continues to find the optimalratio.

As census has grown, the Partnership organizations have also attempted to fine-tune theinterdisciplinary team, both in terms of the number of members a team can effectively serve, andin the proportion of professionals within the team. Cost effectiveness hinges on each teamcarrying a “full” caseload. However, the work associated with each participant varies withcomplexity and acuity, in both health and social domains. Participant needs vary from person toperson and from time to time. In response, the Partnership organizations have adjusted the team’srelative full time equivalents (FTE) of each profession (Nurse Practitioner, Registered Nurse,Social Worker, and sometimes a clerical worker) in different combinations without reaching any


solid conclusions about the “right” mix or ratio to participants. It has become increasingly clearthat a tool to assesses participant complexity and acuity to predict workload would be helpful.

3. What challenges or successes were caused by factors external to the project?

The largest external challenge that Partnership has faced (and will continue to face) is the abilityof the Partnership sites to recruit and retain quality staff in the current marketplace. Theunemployment rate in Wisconsin is extremely low. The Partnership organizations have had toimplement creative solutions to over come this barrier. This challenge has affected all levels ofstaffing, from nurses to daily living assistants.

Another challenge that continues to face Partnership is the changing federal landscape that formsthe backdrop for implementation of the 1115/222 waiver. The Partnership waiver was written torespond to U.S.C 1395. During the negotiation of the waivers, Medicare+Choice (M+C) becamea reality and the regulations were published shortly before Partnership implementation. HCFAchose to contract with Partnership organizations as M+C entities. As a result, the Partnershipprogram, at all levels, has found it necessary to adapt to the new and changing requirements ofM+C as federal policy is defined and regulations are interpreted. Constant vigilance is requiredto evaluate Medicare+Choice requirements against the application, the terms and conditions ofthe waiver and the Partnership protocols adopted in the waiver.

In its approach, the Partnership program seeks to recognize the existing physician relationshipsthat people, newly referred to the program, bring along with them. This has led, in some cases, tothe development of large physician panels serving relatively few enrollees. It is a constantchallenge to organizations to orient physicians to the Partnership approach, manage therelationships with physicians, and communicate effectively with physicians in trying to provideoptimal health and social outcomes to members. As a result, organizations have implemented anumber of strategies to limit growth of the physician panels and enhance the quality of NP/physician relationships. Most of the organizations now request that new physicians added to thepanels serve a minimum number of enrollees. Also, organizations have used their medicaldirectors extensively to assist with communication and orientation in an effort to emphasize theteam approach to case management and fully integrated care.

The budget neutrality requirements under the 1115/222 waiver have also been a challenge for thePartnership Program. The initial establishment of budget neutrality was a matter of muchnegotiation prior to securing the dual waiver. Further, finalizing budget neutrality reportingrequirements was not resolved with HCFA until a year after the waiver became operational.Wisconsin is confident that the Partnership Program will prove itself to be budget neutral. In1999, the first year that the dual waiver became operational, the budget neutrality cap was$3,005; the average capitation paid to the Partnership sites was only $2,513 – a difference of$492.

4. If you are working in collaboration with other organizations, or depend on otherorganizations or institutions to meet the objectives of this project, how did thosecollaborations work?

The Wisconsin Partnership Program is the result of an ongoing collaboration of many entities. Itwould not be possible without the collaborative efforts of the Robert Wood Johnson Foundation,


federal Health Care Financing Administration, Wisconsin Department of Health and FamilyServices, University of Wisconsin-Madison, and the four Partnership organizations. In addition,collaboration with various advocacy groups such as the Wisconsin Coalition of Advocacy andthe Independent Living Centers have played a major role in making Partnership the consumerresponsive program that it is.

The Health Care Financing Administration has shown a real willingness to collaborate in thedevelopment of this innovative program. The agency has demonstrated flexibility and theassigned project officers have been very helpful to Wisconsin in navigating the federalbureaucracy. HCFA was and continues to be of assistance, helping the Partnership organizationsto become fully operational. Federal budget constraints limited staffing at HCFA, so projectofficers were at times overworked and less than fully available.

While the Center for Delivery Systems Development at the Wisconsin Department of Health andFamily Service has had the lead in the planning, development and implementation of thePartnership Program, other segments of State government have also been significantcollaborators. The Division of Health Care Financing has taken the lead in the areas ofcontracting, quality, and capitation rate development. Units of the Division of Supportive Livinghave also been participants in Partnership. Departmental restructuring and related changeinitiatives have both delayed our work and benefited from it. Finally, the support of the fivecounties hosting the Partnership organizations - Dane, Dunn, Chippewa, Eau Claire andMilwaukee - has been critical to the development and implementation of the program.

Within the Department of Health and Family Services, Partnership has led the move away fromregulation of structure and process and moved toward outcomes contracting. This requires us torethink the way government approaches quality, in terms of measures, monitoring, staffing andorganizational responsibilities.

5. With a perspective on the entire project, what have been its key dissemination activities?

With the help of the Robert Wood Johnson Foundation, the State has developed two videos aboutthe Partnership Program. These videos have been extremely well received and will continue tofunction as a key means of dissemination.

The Partnership Program also has a web site (www.dhfs.state.wi.us /aboutdhfs/osf/wpp/osf-wpp-index.htm). This site contains general overview information as well as all of the researchproducts developed by the research team at the University of Wisconsin. The web site alsocontains monthly census data dating back to December 1998 and updated census data ispublished monthly.

Staff from the various Partnership organizations, as well as staff from the State, have presentedat conferences across the nation. The most notable dissemination activity however, is the day-to-day phone discussions with different states and provider types seeking to implement aPartnership-like delivery model for consumers of long term care.


6. What were the project’s other sources of support?

Federal, State, and county funds, and in-kind support enabled the Partnership Program to build asubstantive state and site infrastructure and extend the original RWJF grant from 3 years to 5years in duration.

Federal Medicaid administrative match was requested and approved for state project positionsand direct costs, consultant contracts, and University of Wisconsin research contracts. At the endof the grant, the continuation of the project was ensured when state funds replaced the RWJfunds for the state project positions, and these positions were converted to full-time permanentstate positions.

County funds played a key role in helping to finance start up costs. Each site had a collaboratingcounty that offset expenses up to $500,000 per year for the first three years for staffing and directcosts.

In addition, administrators and policy analysts in the Office of Strategic Finance and Division ofHealth Care Financing provided significant in kind support, particularly during the first twoyears of the grant.

7. What was the significance of what was accomplished by the project?

In the original grant application, we emphasized reducing fragmentation in the care system:“The Partnership Program is designed to eliminate fragmentation in long term careprograms and of the health care system in general. Some harmful consequences offragmentation include:

• Unnecessary Spending: Fragmentation in finance yields cost mismanagement. Eachseparate program and agency seeks to contain expenditures in its own area ofresponsibility, without regard to total cost. Rational acts, such as cost-shifting, contributeto an irrational and undesirable total result.

• Lower Quality of Care: Fragmentation in service delivery means that people depend onmultiple providers who treat them not as a whole person, but as an unconnectedamalgam of broken parts, illnesses, and conditions.

• False Assurance of Quality: Fragmentation in finance and service delivery results in acompartmentalized quality assurance system. Each individual service is held to chosenstandards, but the interrelationships between services are ignored. We are assured thateach “part” is working fine even though the “whole” may be dysfunctional.

• Resistance to Improvement: Fragmentation in management means that managers areresponsible only for “parts” and no one is responsible for the “whole”. Management isthen blinded (and often resistant) to needed improvements.”

To reduce service fragmentation, the Wisconsin Partnership Program has been developed as afully integrated managed long term care program. A unified funding stream eliminatesconflicting incentives – providers are selected and coordinated by a single payer agency. Aunified interdisciplinary team works with the service recipient through all care situations andsettings until death or disenrollment. Care is holistic; cohesive goals are integrated into a single


plan. Quality is considered from the perspective of the member, and across the spectrum ofproviders and care settings.

In many respects, Partnership resembles PACE - the only other fully integrated managed careprogram in the country. However, what are of the greatest significance in Partnership are thedissimilarities from PACE. PACE primary care physicians are employed by the PACE site.While this gives PACE sites greater control in utilization management than Partnership, thesmall physician panel can be a disincentive for people who already have a well establishedrelationship with a primary care physician. Ideally, Partnership allows members to maintain therelationship they have already established with their doctor. Partnership’s services are primarilyhome based and do not rely on a day center as a structure in which to provide services. UnlikePACE, Partnership serves individuals with significant physical disabilities in addition to the frailelderly. Partnership draws on Wisconsin’s rich history of consumer-centered, community basedlong term care to shift the focus from the care provider to the consumer.

The differences from PACE, highlighted above, as well as the more traditional approaches foundin home and community based waivers and Wisconsin’s Community Options Program, qualifyas truly significant variations from a pre-existing service structure in Wisconsin and the country.

Partnership has begun to collect data with the intent of establishing performance benchmarks forcommunity based long term care. Very little is known about what constitutes good performancein health or long term care for frail populations. While PACE tracks some information, it isframed in the context of the PACE model. Wisconsin’s other Home and Community BasedWaiver Programs manage long term care, but are not responsible for participant health services.Managed health care organizations do track health variables, but blend statistics for well and illpopulations. As managed care organizations begin to recognize the value of health screening andtargeted managed care, they may look to Partnership for benchmarks for these specialpopulations.

8. What lessons did you, as a project director of a project in a National Program, learn fromundertaking this project?

1. From vision to reality: Things change. The application to the Foundation for funding thePartnership demonstration was visionary in its scope and ambitious in its expectations. Thereality is that it took a long time to operationalize the vision; some things worked and somethings didn't; and some things – very few – never were accomplished.

2. Prime project manager characteristics required: Patience and persistence. Almosteverything took longer than expected, and there were surprises around every corner. Once weobtained the grant, it took a very long time to get staff positions approved so we could start;and just when we thought the waiver was about to be approved, HCFA reorganized:Persistence.

The sites struggled to enroll members, but they neglected to monitor level of care, so lostmoney; the nurses and social workers started to work as an interdisciplinary team but qualityaudits revealed that they didn't always record what they discussed: Patience.


3. Community-based organizations can learn health care…with the following suggestions tomake things easier:

• Put people on the board of directors who have strategic expertise: marketing, fiscal,human resources and clinical experts help grow the organization from folksy toprofessional.

• Become administrative sooner: put a strong management team in place before youcan afford it. These managers will establish the systems and prepare the plans so thatyou can afford it.

• Be good collaborators. Integrated health and long term care is a collaborationbetween purchaser and provider – the state and the community-based organization –and the relationship should be interdependent and dynamic should foster goodorganizational learning and quality improvement on both fronts.

4. It takes years to build the desired data and quality systems that are needed to supportintegrated health and long term care programs. Start early, and keep at it. Patience andpersistence.

5. Take risks and be flexible. Vision and planning are good, but at some point, take a risk and“just do it.” It is in the doing that the learning occurs. And while you are learning, whenthings are a mess and difficult to sort out and everyone is overworked and testy, be flexiblebecause there’s more than one solution to a problem.

6. While you are learning, build the systems needed to anticipate problems, and to identify andsolve problems quickly when they occur.

7. Don’t ever, ever forget why you are doing this work : to improve the quality of life of veryvulnerable people who want to have the health care and social supports they need to livewhere they want to, to go where they want to, be with the people they want to be with, and gowhen they want to go.

9. What are the post-grant plans for the project if it does not conclude with the grant?

Continued FundingThe operations of the Wisconsin Partnership Program did not end with the RWJ grant. Continuedfunding for state staff previously provided by grant monies was appropriated in the most recentstate biennial budget. Four full time positions and one part time position at the Departmentcontinue to be dedicated to the Partnership Program. This assures that the development ofinfrastructure, research aimed at the refinement of operations, and technical assistance to thePartnership organizations will continue.

Expansion and ReplicationExpansion of the Partnership demonstration continues to be a goal of the Department.Negotiations are underway with the Health Care Financing Administration (HCFA) to allow foran expansion to serve additional target populations. Two of the existing Partnershiporganizations have already been approached by geographically adjoining counties to provideservices and offer greater choice to consumers.


GrantsWisconsin is applying for a grant from the Robert Wood Johnson Foundation –Medicare/Medicaid Integration Program to further research objectives and build clinicalexpertise within the Partnership Program. Experience in demonstrating that clinical pathwaysaddressing the multiple and complex needs of members, particularly people with physicaldisabilities, are lacking or non-existent.

Partnership organizations have experienced a high degree of co-morbidity in their memberships,adding mental illnesses and alcohol and other drug abuse to the complexity of the social andmedical conditions they must address. This added complexity is not recognized in level of careconsiderations and is not reflected in the current method of rate setting. Wisconsin will useadditional RWJ funding to do the research to support and help refine level of care and ratesetting methodologies to better reflect the complexity of the people served.

Developing appropriate indicators of quality specific to the Partnership Program remains achallenge. Efforts are underway to isolate and define measurable, critical indicators of quality inthe Partnership model. Accepted standards of quality that apply to medical or social aspects ofcare do not adequately capture the improvements in consumer outcomes that are facilitated byintegrating medical and social services. Measuring advances in quality facilitated by theinterplay of an integrated service model is evident but not fully understood. We will be seekingan appropriate set of indicators to measure these advances in quality.

DisseminationWisconsin has been and will continue to be a willing provider of information regarding thePartnership Program. We will continue to publish research and develop technical assistancedocuments available to any that request them. Partnership Program has a web site and futureplans include the expansion of this site to provide access to all Partnership materials as well asvideo produced with financial support from the Robert Wood Johnson Foundation during thisgrant.

10. How do you assess the Foundation’s role and the NPO’s role?

In May 1999 a Partnership conference took place in Wisconsin Dells and was attended by stafffrom the various Partnership organizations, State staff, as well as representatives from otherstates planning new approaches to serving people with chronic conditions. Marc LaForce and JayWussow from the Center for Health Care Strategies (CHCS) actively participated in thisconference. Their ability to bring a more global perspective to the work underway in Wisconsinvia the Partnership Program served to emphasize to staff the groundbreaking nature of theirefforts. This encouragement in “Navigating Uncharted Waters” was very helpful.

On a different occasion, Marc and Jay met with management staff from the various Partnershiporganizations and with state staff. This meeting helped Partnership to identify and solidify someof the learning that has taken place over the life of the grant. This learning is currently beingarticulated in a monograph to aid in its dissemination to other interested parties. This monographis a joint effort of the Wisconsin Partnership Program and the CHCS.

Over the life of the grant, the funding and other support provided by the Robert Wood JohnsonFoundation has been critical to the development of the infrastructure, the research and training,


marketing, and the dissemination activities of the Wisconsin Partnership Program. In 1997, theFoundation granted a no-cost extension of the original grant. During the extension, Wisconsinwas able to complete its negotiations with HCFA and obtained approval of Wisconsin’s1115/222 waiver request. The waiver was implemented in 1999 and all four Partnershiporganizations are now operating fully integrated, Medicare/Medicaid managed care programs.The State of Wisconsin and the Partnership organizations are grateful to the Robert WoodJohnson Foundation for helping make the Partnership Program a viable reality for the membersserved in the program.

The reporting activities required by the Foundation provided the impetus to periodically assessthe progress being made in the program as a whole and at each of the various organizations. It iseasy to get caught up in wrestling with individual issues and miss the progress being made overtime. The quarterly and annual reports were often the catalyst for us to take the time to gain someperspective.

We are grateful to the Robert Wood Johnson Foundation for their support andcooperation in the development and implementation of the

Wisconsin Partnership Program.


FINAL GRANT REPORT BIBLIOGRAPHY

Building a Statewide System of Consumer-Responsive, Integrated Carefor People with Chronic Illness or Disability

Robert Wood Johnson Grant # 23246October 1, 1994 – December 31, 1999(no-cost extension 10/1/97 – 12/31/99)

Book Chapters• Zimmermann, D. & Bowers, B. “Satisfaction surveys and other sources of information on

quality in long term care.” Satisfaction Surveys in Long Term Care. Edited by J. Cohen-Mansfield, F. Ejaz & P. Werner. New York: Springer Publishing Company, 2000.

Journal Articles• Bowers, B., Esmond, S. & Jacobson, N., The relationship between staffing and quality in

long term care facilities: Exploring the views of nurse aides. Manuscript submitted forpublication to Journal of Nursing Care Quality, forthcoming.

• Lutz, B. & Bowers, B., Patient-centered care: Understanding its interpretation andimplementation in health care. Scholarly Inquiry for Nursing Practice, forthcoming.

Research Reports and Products• Bowers, B., Esmond, S. & Holloway, E. Quality Care: The Perspective of Frail Elderly.

Data based research report based on analysis of interviews with elderly consumers in WI.Subjects include individuals enrolled in PACE and WPP programs at Elder Care of DaneCounty, as well as those living independently in the community. Prepared for the Departmentof Health and Family Services and the Robert Wood Johnson Foundation, 1996.

• Bowers, B., Joyce, M. & Esmond, S. Quality Care: The Perspective of Physically DisabledConsumers. Narrative report of findings based on analysis of interviews with individualswith physical disabilities and their caregivers about care experiences. Prepared for theDepartment of Health and Family Services and the Robert Wood Johnson Foundation, 1996.

• Bowers, B., Holloway, E. & Esmond, S. Creating an Integrated, Patient-Centered CareTeam. Data based research report prepared for the Department of Health and Family Servicesand the Robert Wood Johnson Foundation, 1996.

• Bowers, B., Esmond, S. & Canales, M. Supervision in Wisconsin’s Long Term SupportNetwork . Data based research report prepared for the Department of Health and FamilyServices, 1996.

• Bowers, B. & Esmond, S. Perspectives on Choice, Responsibility, and Participation:Community Living Alliance, Madison, WI. Narrative report of findings based on analysis ofinterviews with individuals with physical disabilities about their role and preferences onparticipation in the program. Prepared for the Department of Health and Family Services andthe Robert Wood Johnson Foundation, 1999.


• Bowers, B. and Esmond, E. WPP Model Quality Improvement Reviews. Designed for use byintegrated care sites serving frail elderly and physically disabled populations, these reviewsprovide information to organizations about specific areas of care and service delivery (systemlevel and direct service level) identified by both providers and consumers as important toquality of care and quality of life. Specific review areas include: Integrating ConsumerPreferences into Plans of Care, Personal Care Services, Transportation Services, andMonitoring Medication Profiles. Prepared for the Department of Health and Family Servicesand the Robert Wood Johnson Foundation, 1997.

• Bowers, B. & Esmond, S. Quality Research Team’s Consultation with Partnership Sites.Narrative report outlining Model QI Review plans at three Partnership Sites. Prepared for theDepartment of Health and Family Services and the Robert Wood Johnson Foundation, 1997.

• Bowers, B. & Esmond, S. Quality Research Team’s Review of Model QI Studies Conductedat Partnership Sites. Narrative report analyzing three Partnership site quality improvementstudies, significant findings, and recommendations for future studies. Prepared for theDepartment of Health and Family Services and the Robert Wood Johnson Foundation, 1998.

• Bowers, B. & Esmond, S. Wisconsin Partnership Program: Member Evaluation. Researchbased evaluation designed for use by members (consumers) enrolled in integrated careprograms to evaluate quality. Evaluation areas, identified by both consumers and health andlong term care providers, correspond to quality care/service areas outlined in the ModelQuality Improvement Reviews (see above). Prepared for the Department of Health andFamily Services and the Robert Wood Johnson Foundation, 1998.

• Bowers, B. & Esmond, S. Interdisciplinary Team Curriculum for Providing Integrated,Consumer Centered Care. Prepared for the Department of Health and Family Services andthe Robert Wood Johnson Foundation, 1998; revised 1999. Includes the following twomodules:

Module I: Team Members Professional Identification & Cross-Discipline AwarenessDesigned to assist team members in understanding discipline-specific attitudes, priorities,logic and expertise and to reflect on the professional expertise on the interdisciplinaryteam, the similarities and differences among the professionals, and how professionalidentification can affects practice.

Module II: Providing Consumer-Centered Care (in development)Designed to explore how team members from health and long term care settingsconceptualize consumer-centered practice differently, increase appreciation for thesedifferences and demonstrate how these differences can be used in care planning to thebenefit of the consumer.

• Esmond, S., Griffin, M. and Mirk, A. Wisconsin Partnership Program Draft OrientationOutline for Personal Care Services. Outline of recommended orientation and trainingactivities developed by members of the Partnership Training Steering Committee. Theoutline integrates many of the WPP Quality Research findings. It is designed for use byadministrative staff in charge of developing and conducting personal care staff orientation


programs in integrated care settings. Prepared for the Department of Health and FamilyServices and the Robert Wood Johnson Foundation, 1998.

• Esmond, S. & Bowers, B. Enrolling New Members in a Consumer Centered, IntegratedProgram. Case study of one interdisciplinary team’s approach to intake and enrollment ofnew program members. Identifies the complexities to designing integrated, consumercentered intake/enrollment systems. Prepared for the Department of Health and FamilyServices and the Robert Wood Johnson Foundation, 2000.

• Esmond, S. & Bowers, B. Consumer Centered Careplanning in Integrated Care Programs.Narrative report on the challenges to creating consumer-centered careplans, as well asspecific initiatives designed by Partnership program staff to address these challenges.Prepared for the Department of Health and Family Services and the Robert Wood JohnsonFoundation, 2000.

Journal Articles“State Receives Waivers to Combine Medicaid, Medicare Funding,” BNA’s Health Care Policy.Vol. 6 (November 16): no. 45, 1998.

Brochures“Wisconsin Partnership Program.” Department of Health and Family Services, Office ofStrategic Finance. May 1999. Also available in Hmong and Spanish.

NewslettersWPP Project Notes. Madison, Wisconsin, Department of Health and Family Services, Office ofStrategic Finance. Two issues; Fall 1996 and Spring 1997. Approximately 300 copies mailed perissue.

Sponsored Conference, Meetings, and Workshops“Capture the Learning-First Annual Partnership Retreat,” April 1-2, 1997, Madison, Wisconsin.Attended by over 200 people from Partnership sites, the State, county, University of WisconsinSchool of Nursing, and other stakeholders.

“Navigating Uncharted Waters,” May 25-26, 1999, Wisconsin Dells, Wisconsin. Attended byover 200 participants, which included staff from the various Partnership organizations, the Stateand county, and the federal Health Care Financing Administration, as well as representativesfrom other states interested in the Partnership Program model. Four presentations given:

• “Navigating Uncharted Waters,” F. Marc LaForce, M.D.• “A Fleet Exercise,” William Clark.• “Consumers at the Helm,” Kevin Mahoney, Ph.D.• “The Crew is the Glue: Interdisciplinary Teamwork in Emerging Health Care Systems,”

Theresa Drinka, Ph.D.• The conference also hosted 17 excursion sessions for program participants.


Presentations• Mary Rowin and Barbara Bowers, “Quality Assurance Retreat,” October 28-29, 1996,

College Park, Maryland. University of Maryland Center on Aging and the Robert WoodJohnson Foundation.

• Barbara Bowers, “Aging Network in Transition Forum,” November 5, 1996, Madison,Wisconsin.

• Fran Genter, Judy Hodgson, and Mary Rowin, “Wisconsin County Human ServicesAssociation (WCHSA) Fall Conference,” December 4-6, 1996.

• Thomas Hamilton, “Alliance for Health Care Reform,” March 10, 1997, Washington, D.C.Briefed congressional aides and media on Wisconsin Partnership Program and issues servingdually eligible populations.

• Mary Rowin, John Bott, Gail Gaustad, and Karen Musser, “Developing the Components of aConsumer-Focused System of Care,” at the 1997 Annual RWJ Grantee Meeting, April 30 -May 1, 1997, San Francisco, California.

• Barbara Bowers, “Excellence in Community-Based Case Management,” June 4, 1997, St.Paul, Minnesota.

• Mary Rowin, presentation to the Advisory Committee to the Wisconsin Department ofHealth and Family Services Medicaid program, June 4, 1997, Madison, Wisconsin.

• Mary Rowin, to the Partners’ Planning Managed Care Conference for People with PhysicalDisabilities, July 16, 1997, Minneapolis, Minnesota.

• Barbara Bowers and Thomas Hamilton, “Consumer Views of Quality,” at the Annual StateHealth Policy Conference, August 10, 1997, Portland, Maine.

• Sharon Ryan and Karen Hodgson, presentation to the American Associates for MentalRetardation, September 11, 1997. Presenters: Sharon Ryan and Karen Hodgson.

• Thomas Hamilton, presentation at the Long Term Care Workshop, Agency for Health CarePolicy and Research, Washington D.C., October 1997.

• Mary Rowin, “WPP/County Collaborations,” at the Wisconsin Statewide Long Term SupportConference, October 1997.

• Mary Rowin, presentation to the 20th Century Coalition of United Cerebral PalsyOrganizations, October 3, 1997, Milwaukee, Wisconsin.

• Thomas Hamilton, presentation at the Annual State Health Policy Conference, August 10-12,1997. Portland, Maine.


• Mary Rowin, “Managed Care and Persons with Disabilities and Chronic Illness,” AHCPRUser’s Liaison Program, Chandler, Arizona, November 1997.

• Thomas Hamilton, presentation and discussion of dual Medicare/Medicaid waiver requestmade to Nancy Ann Min Deparle, HCFA Administrator, March 1998.

• Barbara Bowers, Mary Rowin, and Lisa Kregel, “Consumer-Centered Care in IntegratedPrograms,” Maryland Center on Aging and Robert Wood Johnson Foundation, Baltimore,May 1998.

• The following presentations were made at the Long Term Care Redesign Care ManagementDemonstration Workshop for counties on May 18 and 20, 1998:− “Case Management,” Sara Roberts and Linda Burns.− “Cost and Service Utilization,” Tom Schaefer and Sherrel Walker.− “Consumer Involvement,” Lynn Breedlove, Karen Hodgson, and Owen McCusker.− “Building a Provider Network,” John Bott and David Sievert, presenters.− Organizational Change,” Chuck McLaughlin, Jeanne Prochnow, and Meg Gleeson.

• Barbara Bowers, “Recognizing Consumer Priorities in Organizational Design and ServiceDelivery,” New England Consortium, Edmund Muskie School of Public Service, NewHampshire, July 1998.

• Mary Rowin, presentation to a Health Systems Seminar regarding Medicare/MedicaidIntegration, University of Wisconsin-Madison, July 26, 1998.

• Barbara Bowers, “Designing Integrated, Consumer-Centered Care Systems,” Grant County,August 1998.

• The following presentations were made at the Family Care Workshop for Care ManagementOrganization Demonstration Sites in Wausau, Wisconsin on August 25-26, 1998:− “Quality Management in Community-Based Organizations,” Julie Horner, Barbara

Bowers, David Sievert and Lynn Polacek, presenters.− “Assessment, Care Planning and Resource Allocation,” Lynn Polacek and Alice Mirk.− “Managing Cost and Quality,” Tom Schaefer, Larry Paplham, and Jack Reiners.

• Barbara Bowers, Owen McCusker, and Karen Hodgson, “Integrated Care Models for Peoplewith Physical Disabilities,” September 1998, Houston, Texas.

• Steve Landkamer, presentation to the county COP coordinator meeting, Appleton,Wisconsin, September 1998.

• Mary Rowin, presentation at the Building Health Systems Program Annual Grantee Meeting,September 17-18, 1998, Baltimore, Maryland.

• Meg Gleeson and Chris Hess, “Lapham Park Residential Complex Venture Project,” at theNational Council on Aging Annual Conference, November 1998, Washington, D.C.


• Mary Gavinski, M.D. and Jeanne Prochnow, “The Changing Face of Long Term Care of theElderly,” November 11, 1998, Milwaukee, WI. Sponsored by Aurora Health Care, OlderAdult Services.

• Steve Landkamer, presentation at the Medicare/Medicaid Integration Program TechnicalAssistance Workshop, March 4-5, 1999, College Park, Maryland.

• Karen Musser and Lora Wiggins, “Function and Composition of the Interdisciplinary Team,”March 25, 1999, Massachusetts. Invited presentation to the Massachusetts Medicaid SeniorCare Organization Technical Assistance Workshops.

• Jeanne Prochnow, “Wisconsin Elder Care: Legal and Financial Issues, 1999”, April 15, 1999,Milwaukee, WI.

• Kirby Shoaf, “Alternative Models of Integrated Programs,” May 1999, Washington, D.C.National PACE Association Annual Public Policy Forum.

• Lora Wiggins and David Sievert, “Tips for Starting and Managing a Senior CareOrganization,” October 4, 1999, Massachusetts. Invited conference presentation to theMassachusetts Medicaid Senior Care Organization Technical Assistance Workshops.

• Barbara Bowers with Paul Saucier, “Designing Guidelines for Consumer Centered CareSystems,” Association for Health Care Policy Research (AHCPR) User Liaison Conference,December 1-2, 1999.

• Jeanne Prochnow and Steve Landkamer, “Designing Health Care Systems that Work forPeople with Chronic Illnesses and Disabilities,” December 2, 1999, Houston, TX. Sponsoredby the National Academy for State Health Policy.

Press Release“State’s Health Care Partnership Program Approved,” press release issued by WisconsinGovernor Tommy G. Thompson, regarding HCFA’s approval of Wisconsin’s 1115/222 waiver.October 26, 1998.

WWW, Electronic Media, and Audio-Visuals• www.dhfs.state.wi.us/aboutdhfs/osf/wpp/osf-wpp-index.htm. Provides information about the

Wisconsin Partnership Program. Madison, WI: Department of Health and Family Services.March 1999; average 375 viewers per month.

• Wisconsin Partnership Program (11-minute audio-tape). WI Department of Health andFamily Services, 1999. 65 copies produced; 35 distributed. Available free of charge.

• Wisconsin Partnership Program – Participants and Their Stories. WI Department of Healthand Family Services, 2000. 50 copies produced; 10 distributed. Available free of charge.

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